Even with all the weapons  heightened public awareness
campaigns, safe sex advisories, needle exchange programs,
treatments such as zidovudine (AZT), protease inhibitor "cocktails"
and most recently, highly active antiretroviral therapy
(HAART)  deployed against the HIV/AIDS epidemic in two
decades, the disease is still winning, according to panelists at a
recent women's health seminar. Further, they point out, the
epidemic's relentless advance is no more increasingly evident than in
the world's women and children.

Continued...

Dr. Neal Nathanson talks about the AIDS epidemic.

"The epidemic abroad is quantitatively so much larger than the one
we face here...[the epidemic] is particularly intense in Africa," said
Dr. Neal Nathanson, NIH associate director for AIDS research and
one of four presenters at a recent seminar sponsored by the Office
of Research on Women's Health.

State of the Epidemic

In his overview, "AIDS in Women: Epidemiology and Control in
Africa, the Third World, and the United States," he said the
estimated number of people living with HIV/AIDS by the end of
1999 was 23.3 million in sub-Saharan Africa and 920,000 in the
United States. In Africa, prevalence and number of new cases are
both increasing each year. In the U.S., 800,000 people are estimated
to be living with HIV/AIDS; 300,000 of those can be considered to
have AIDS already, according to Centers for Disease Control and
Prevention classifications.

"When an epidemic becomes this big," Nathanson said, "usually it
levels out and becomes endemic, but in fact the epidemic is still
advancing...We are not getting on top of this epidemic from a public
health point of view."

Another thing about the U.S. epidemic is that it has changed
radically in terms of the population that is affected, Nathanson
added, noting that heterosexual transmission is the primary mode of
transmission in developing countries. "In the past in the U.S., it has
been much more of a disease among men than women, although
that's rapidly changing. It has become much more an epidemic of
minorities, moving from a little more than a third to at least
two-thirds of the population, and much more of a problem of
women," who now account for at least one quarter of the epidemic
and that number is rising.

"The good news is that HAART is quite effective," he said,
"resulting in a remarkable drop in the death rate, which is now
plateaued at 50 percent of the peak  20,000 [deaths] in the
last year, as opposed to the 40,000 a few years back."

He mentioned the epidemic's dramatic impact in Africa. Life
expectancy  which had been improving  in
sub-Saharan Africa has plummeted and "this is entirely due to the
AIDS epidemic," Nathanson continued.

He did have some relatively good news from Uganda: A
combination of social marketing, fear and concern stemming from
the very high incidence of deaths and infections, and an
acknowledgement that there is a lack of treatment, have all led to
some safer sex practices, a reduction in partners, an older age of
beginning sexual activity, and more use of condoms.

"As a result," he concluded, "there's been a rather remarkable drop
in prevalence. That's a very important sentinel. [It indicates] there
are ways one can put the brakes on the epidemic, even in countries
with limited resources."

Still, he said, a much higher proportion of new infections and
existing infections in Africa are among babies and young children.
Postpartum infection is still high there, as well as a considerable
amount of transmission via breastfeeding.

Preventing Mother to Child Infection

Taking up where Nathanson's talk left off, a firsthand account of
"Recent Advances in the Prevention of HIV Perinatal Transmission"
was offered by Dr. J. Brooks Jackson, professor and vice chair of
pathology for clinical affairs at Johns Hopkins, who has spent 10
years conducting clinical prevention studies in Uganda.

Dr. J. Brooks Jackson

The substantial progress made in preventing perinatal transmission
by the United States paved the way for the recent successes in
developing countries, he said. The number of HIV-infected women
who deliver babies in the U.S. every year has been fairly steady at
between 6,000 and 7,000 per year. Over the years, with the use of
AZT and now combination therapy, the number of perinatally
acquired HIV cases has dropped considerably from about 1,500 per
year to "probably less than 300 infants born in 1999 with HIV,"
Jackson said. In contrast, an estimated 700,000 infants in developing
nations will be infected with HIV by their mothers during delivery;
the number of babies infected rises even further when counting
transmissions via breastfeeding.

Although most of the preventive regimens used in this country are
far too expensive  about $800 per mother/child for AZT,
for example  to be adopted by developing nations,
researchers supported by NIH and working in Uganda have been
able to produce measurable results with other preventive therapies
such as nevirapine  a single dose of which costs $4 for each
mother and each child, according to Jackson.

"While very successful here," he explained, "it's very difficult for
governments in developing countries to be able to afford [an $800
regimen], where healthcare expenditures are typically $3 to $10 per
person."

Saying that the search must continue for alternative therapies, he
outlined six requirements for new treatments: they must be safe,
feasible, simple, efficacious, inexpensive, and able to be delivered
peripartum (when most transmissions occur).

Jackson concluded by reporting non-cost related obstacles to getting
the therapy to pregnant women in some parts of Africa, including
slowness of governments to license and distribute the drug;
ignorance about the drug's benefits; and requirements that women
first undergo testing and counseling, which is more expensive than
the drug regimen.

"We think the nevirapine is safe and will be effective in preventing
perinatal transmission," Jackson said, "and it is deliverable in
sub-Saharan Africa and other resource-poor settings, but it does
need to be translated into public health policy."

'Treatment in the Real World'

Dr. Victoria Cargill of NIH's Office of AIDS Research discussed
"Treatment Issues and Challenges in Women," bringing firsthand
experience from closer to home  inner city Cleveland.

Dr. Victoria Cargill

"There certainly have been gains in the epidemic," she began,
"however, the survival advantage has not been as profound in
certain communities, particularly communities of color. Drug
resistance continues to be a real consequence of treatment. Being
compliant with one's medication continues to be a significant
challenge, and there are major gaps in medication access."

Explaining that "HIV in women reflects not just one epidemic, but
overlapping epidemics  epidemics of sexually transmitted
diseases, alcohol and drug use, poverty and violence," Cargill
explored several practical concerns often overlooked: some women's
lack of knowledge about available treatments, their sometimes
limited access to care, a mistrust of the medical establishment, and
the competing needs of a woman's family and home life.

To illustrate her point about effective caregivers having to know a
woman's life circumstances as well as her HIV status  or
what she termed "survival collides with HAART: treatment in the
real world"  Cargill described three HIV-positive women
she had seen in her practice: A 52-year-old African American
intravenous drug user addicted to heroin and crack cocaine,
who  in order to support her drug habit  routinely
fenced the hospital supplies she was prescribed and who had been
subsequently dismissed from five previous practices; a 38-year-old
Latina who had four daughters  three of them already
diagnosed with HIV  and an abusive partner, was found to
be 6 weeks pregnant and without money for housing; and a
15-year-old juvenile delinquent with a history of 10 sexually
transmitted disease episodes in the last 2 years who claimed, upon
being informed of her HIV-positive status, "I don't need no damn
drugs."

In conclusion, Cargill shared several lessons she has learned from
treating such women: Learn to accept a less-than-perfect solution,
assume nothing, and above all, know and respect your patient's
needs.

"Therapy in this setting requires a lot of creativity," she said. "We
have to be a partner with our patient. What may be top on my list is
starting therapy; what may be top on her list is having housing and
food for her children. We have to meet in the middle somewhere."

'Stealthy Prevention' Needed

Finally, Dr. Zeda Rosenberg, scientific director of the
NIAID-funded HIV Prevention Trials Network at Family Health
International, offered insight into the basic mechanics of HIV
transmission in her presentation, "Approaches to Preventing HIV in
Women."

Dr. Zeda Rosenberg

Focusing on female-initiated prevention strategies, she said, there is
a strong rationale for developing, for example, a topical microbicide
that is both biodiffusable and bioadhesive  able to reach the
"mountains and valleys" within the vagina, and stay in place during
sex. It's also important, she noted, that whatever preventive is
developed not interrupt the various natural defense systems of the
vagina.

Acknowledging that scientists still are not sure exactly where in the
female genital tract HIV transmission occurs, she said it is important
that researchers designing prevention methods for women consider
the intricacies of the female anatomy. Somehow, Rosenberg
explained, HIV manages to get past the natural defense mechanisms
within the vagina.

Agreeing with Cargill, Rosenberg said to stem transmission in
women effectively, developers must consider the circumstances of
women's lives.

"Most women are infected by their primary partner," she explained,
"and male condoms are less likely to be used during these
encounters." In addition many women face a high prevalence of
nonconsensual sex, and sex with nonmonogamous partners.
Therefore, a stealthy prevention method needs to be developed so
women can use it without informing their partners.

In response to a question about how to reach the seemingly
unreachable women who are needed to test new therapies,
Rosenberg gave advice that could summarize the seminar: "Don't do
business as usual. You have to provide transportation. You have to
provide childcare. We have recruiters on the streets at 2 in the
morning. You don't wait for these women to come to you."